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Initial Adding Services Jordan School District Documentation of

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JORDAN SCHOOL DISTRICT | February 2020
Initial
Adding Services
Jordan School District
Documentation of Student Level of Performance- Secondary
Student Information:
Name:
Date of Birth:
Student #:
Primary Language of Student:
Primary Language in Home:
If Primary Language is other than English, contact your school’s ALS Teacher Specialist before proceeding.
Date ALS Teacher Specialist Contacted:
By:
WIDA Score:
Referred By:
School:
Grade:
Social/Emotional
Academic
Parent notified of initial concern on:
By:
Communication Log with Parent:
Date
Contact Made By
Issues discussed
* If parent requests testing, the LEA completes the Special Ed Testing Request Form and simultaneously begins response to
intervention(s) and formal assessment as soon as possible.
Historical Performance in Area(s) of Concern: Must include data over multiple years from primary (K-3), intermediate (4-6),
Middle School and/or High School.
Test Results: (e.g. State tests, DIBELS, SRI Lexile, Fountas & Pinnell, Running Records, Language Arts Benchmark,
Math Benchmark, Math Unit Test, JSD Writing Rubrics/Utah Compose).
Name of Test:
Grade:
Score:
Name of Test:
Grade:
Score:
Name of Test:
Grade:
Score:
Name of Test:
Grade:
Score:
Name of Test:
Grade:
Score:
Name of Test:
Grade:
Score:
Historical Attendance: Concern Not Concern
Data (If concern): ______________________________________________
Current Levels of Performance: (e.g. common formative assessments)
Assessment:
Date:
Level:
Assessment:
Date:
Level:
Assessment:
Date:
Level:
Grades in Areas of Concern:
Subject:
Year:
Qtr Grdes:
Subject:
Year:
Qtr Grdes:
Subject:
Year:
Qtr Grdes:
Hearing/Vision: (If student fails, follow-up)
Date:
Pass
Fail
Date:
Pass:
Fail
Discipline/Suspension Data: (reason, length of time)
____________________________________________________________________________________________________________
Has this student ever been referred/received special education services?
Yes No If yes, when? ______________________
Has this student ever been retained?
Yes No If yes,
when?______________________________________________
Student’s Attendance:
Concern No Concern Comments: ________________________________________
JORDAN SCHOOL DISTRICT | February 2020
In order to further assist in targeting skill deficits and selecting appropriate scientifically research-based interventions, identify
the specific area(s) of concern, which have been reviewed during PLCs.
Area(s) of Academic Concern (check the targeted skill deficit):
Reading
Writing
Math
Phonemic Awareness
Conventions/Grammar
Number & Operations:
Phonics
Sentence Structure
(number sense, order of operations, math facts)
Fluency
Word Choice/Vocabulary
Algebra: Expressions/Equations
Vocabulary
Expresses Ideas/Opinions/Thoughts
(variables, solving, simplifying)
Comprehension
Functions & Relationships
(graphing, reasoning, problem solving)
If there is only one area of general academic concern, two interventions must
be documented in that area. If there is more than one area of general academic
concern, at least one intervention must be documented in each area.
Geometry
Intervention Data Summary(s): Attach a graph with the trend line and slope that specifies the targeted intervention(s) in each area of academic concern. Six or
more data points must be collected in each area of academic concern.
Area(s) of Social/Emotional/Behavioral Concern: Please consult with the School Psychologist.
Social
Describe:
Emotional
Describe:
Behavioral
Describe:
Intervention Data Summary(s): Attach a graph with the trend line and slope that specifies the targeted intervention(s) in each area of concern as deemed
appropriate based on consultation with the School Psychologist. Six or more data points must be collected in each area of concern.
Area(s) of Oral Communication Concern (check all that apply): Please consult with the Speech Language Pathologist.
Articulation
Incorrectly uses developmentally/age appropriate speech sounds and/or does not speak clearly during
conversation.
Stuttering
Does not speak smoothly without interruption and/or repetition of sounds or words.
Voice
Voice is hoarse or has an unusual quality.
Receptive Language
Does not understand directions, questions, and/or academic vocabulary.
Expressive Language
Does not speak in complete sentences, does not use correct grammar, and/or is not able to tell a
story or explain an event.
Social Communication
Does not interact/communicate appropriately with peers and adults in social and academic settings.
Intervention Data Summary(s): Attach the Response to Intervention Tracking Tool for targeted intervention(s) in each area of concern as deemed appropriate
based on consultation with the Speech Language Pathologist.
Other Concerns: Please consult with the special education team. (check all that apply)
None
Motor
Sensory
Medical
To be completed by The Local Education Agent (LEA) Representative after the Response to Intervention Tracking Tool is
done.
Based on the above area(s) of concern and documentation of the student’s progress using scientifically research-based
interventions, it is recommended that:
No further action is needed (Specify Reason):
Progress is being made, continue with scientifically research-based interventions
504 Evaluation
Additional scientifically research-based interventions needed
Special Education referral
Signature of LEA
Date
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Completed 20 February 2021

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